Cost Burden of Rigid Internal Fixation in Craniomaxillofacial Trauma Care in Low‐ and Middle‐Income Countries

Abstract Fractures of the craniomaxillofacial (CMF) skeleton cause significant morbidity and mortality in low‐ and middle‐income countries (LMICs). Despite this, quality CMF trauma care is lacking for the majority of the world's population. There is a paucity of literature describing the costs of standard‐of‐care open reduction internal fixation (ORIF) for CMF fractures in LMICs. We consider the cost of a six‐hole plate with six screws (SHPS), standard materials used in ORIF for CMF fractures, as a percentage of gross domestic product (GDP) per capita to ascertain the cost burden to patients. Hospital pricing catalog data at 14 LMIC institutions were queried. On average, the SHPS cost represented 10.2% of the GDP per capita in sampled LMICs. We highlight manufacturing costs, import taxes, and lack of subsidized health care as factors contributing to the significant cost burden of ORIF in these areas. Future work should characterize additional financial and socioeconomic barriers to optimal CMF care.


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lobal morbidity and mortality from trauma exceed that of HIV/AIDS, malaria, and tuberculosis combined, yet trauma and its management garner little comparative attention. 1Craniomaxillofacial (CMF) fractures represent a significant component of overall trauma in low-and middle-income countries (LMICs). 2 Open reduction internal fixation (ORIF) is the gold standard for CMF fractures, but patients in LMICs must purchase their own plating supplies.As a result, less than 20% of these patients undergo ORIF for CMF fractures. 3ior work has broadly described the state of CMF care in LMICs; however, there is a paucity of literature describing the costs of ORIF in LMICs. 4A focused review on ORIF costs can help to identify specific opportunities for decreasing financial barriers.We aim to characterize ORIF material cost burden by considering the cost of a single six-hole plate and six screws (SHPS), standard ORIF materials, as a proportion of gross domestic product (GDP) per capita.

Methods
A group of 14 established CMF surgeons, currently practicing in LMICs, were queried as to the costs of the select ORIF materials at their respective hospitals.Cost to patients was extracted from hospital catalog pricing data.Costs were similarly obtained from local academic centers in the Boston area for comparative analysis.LMICs are defined as countries with a gross national income per capita, as determined by the World Bank in 2019, of less than $12,375. 5GDP per capita, as reported by the World Bank in 2019, was used as a metric of average individual income. 5All costs are reported in 2019 US dollars.The cost burden is defined as the cost of the select ORIF materials expressed as a proportion of GDP per capita.Data analysis was performed in Excel (Microsoft Corp).This study was exempt from the Mass General Brigham Institutional Review Board.

Results
The mean SHPS cost among the 14 sampled LMICs was $238.38.The cost was lowest in Rwanda ($4.79) and highest in Gabon ($1000).The mean cost burden (SHPS cost/GDP per capita) among sampled LMICs was 10.2%.The cost burden was lowest in Rwanda (0.6%) and highest in Cameroon (23.2%).The mean SHPS cost at 3 local Boston academic centers was $692.21; this represents 1.1% of GDP per capita (Table 1).

Discussion
The majority of global trauma occurs in LMICs, causing significant morbidity and mortality. 1Elucidating barriers to CMF trauma care is imperative to improving access and patient outcomes. 6We show that the mean cost burden of SHPS was 10.2% (range 0.6%-23.2%) in the sampled LMICs.This cost burden is multifactorial with manufacturing costs, import taxes, and lack of subsidized health care playing critical roles.
Manufacturing titanium, which is used for ORIF materials because of its strength and biocompatibility, is a resource-intensive process.Consequently, titanium is more expensive than other more readily available metals in LMICs. 4In high-income countries, the use of bioresorptive materials has shown promise in decreasing overall trauma costs by reducing reoperative rates, without compromising patient outcomes. 7Such innovations offer opportunities and could help to cut costs in LMICs. 8However, similar to titanium, these materials are not commonly available in LMICs.
Manufacturing costs alone cannot explain SHPS costs in LMICs.The highest SHPS cost reported in our study was in Gabon.This may be due to high import taxes which limit the supply of medical devices to Gabon and other LMICs. 9The cost of importing medical devices in Gabon contributes to the nation's striking total health care costs which represent 21.8% of its GDP per capita. 10SIGN International is a nonprofit organization that coordinates donations of ORIF materials for hip surgery to LMICs. 11evelopment of similar donation platforms for CMF materials may help offset costs.
Interestingly, with the exception of Gabon, SHPS costs were lower in all sampled LMICs than in Boston centers.This may be due to intrinsic market limits in LMICs which cannot tolerate costs as steep as US markets can.While SHPS costs in LMICs were lower, the cost burden was significantly higher when compared to Boston.This burden is exacerbated by the comparative rarity of medical insurance in LMICs.Where most patients in the United States are shielded from a significant proportion of the material cost by insurance, only a minority of LMICs have national medical insurance programs that subsidize costs.12Indeed, health care system refinancing is needed in LMICs.
This study has notable limitations.ORIF material costs represent an important but limited portion of the barriers to CMF care.Other financial costs (ie, surgeon/ anesthesia fees, perioperative care, transportation costs), shortage of CMF surgeons, lack of reliable, efficient referral patterns, and socioeconomic and environmental factors were not considered.Additional research should characterize such factors and their impact on access to CMF care in LMICs.While a more comprehensive review of access to CMF care would be valuable, a targeted review of the cost burden of ORIF materials may help to guide practical solutions for decreasing costs.Separately, data regarding median household income was not universally available from all countries.Thus, GDP per capita, a measure of total domestic economic output per person, was used as a proxy for median income.GDP per capita is a broad measure and lacks the specificity requisite for considering cost burden.In resource-limited settings where national surveys are not easily conducted, this may be the most robust measure of median income available.Cost burden is defined as the cost divided by the GDP per capita.
b Eswatini was formerly known as Swaziland.

Conclusion
Our study demonstrates the significant cost burden of standard CMF care in LMICs.Future work should detail other barriers and focus on the development of innovative solutions for improving access.

Table 1 .
Costs of a Single Six-Hole Plate With Six Screws, GDP Per Capita, and Calculated Cost Burden for Sampled Low-and Middle-Income Countries and Local Boston Academic Centers Abbreviations: BCH, Boston Children's Hospital; BMC, Boston Medical Center; GDP, gross domestic product; MEE, mass eye and ear; MGH, Massachusetts General Hospital; USD, US dollars.a